Composition for the prevention and/or treatment of respiratory tract disorders

ABSTRACT

The present invention relates to a composition comprising or, alternatively, consisting of an effective amount of a mixture which comprises at least, or consists of: a) an extract of  Pelargonium sidoides ; b) an extract of  Adhatoda vasica ; and c) N-acetyl cysteine for use in a method for the preventive or therapeutic treatment of at least one respiratory tract disorder in a subject, wherein said treatment method comprises the administration of said composition to the subject.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a § 371 national phase of International ApplicationNo. PCT/IB2018/057555, filed on Sep. 28, 2018, which claims the benefitof Italian Application No. 102017000109080, filed on Sep. 28, 2017,which applications are incorporated by reference herein.

The present invention relates to a composition for use in a method fortreating respiratory tract disorders or diseases, wherein saidcomposition, in any form of pharmaceutically acceptable administrationthereof, comprises a mixture comprising or, alternatively, consisting ofan extract of Pelargonium sidoides, an extract of Adhatoda vasica andN-acetyl cysteine.

The respiratory system consists of different anatomical structures,which serve to ensure its correct functioning.

It has the function, in fact, of exchanging gases, oxygen and carbondioxide, between tissues and the outside environment, a function that isfundamental for all of the body's cellular processes and thus for itslife.

Anatomically, two macro areas can be distinguished, the upper and lowerairways. The former consist of the nose, pharynx and associatedstructures, whilst the latter consist of the larynx, trachea, bronchiand lungs, whose actual respiratory surface consists of alveoli. Thiscomplex system of organs serves to prepare air for its entry into thelungs by filtering out any particulate matter and heating andhumidifying it. Particles larger than 10-15 microns can be blocked atthe level of the nasal cavities thanks to the hairs and the presence ofmucus, which traps these particles, as well as precipitation due toturbulence, mediated by the turbinates, which divert the direction ofair. Mucus is layered on top of the periciliary liquid, in which thevibratile cilia of epithelial cells are immersed. Particles of about 10microns reach the trachea, are trapped in the mucus and then eliminatedby ciliary movement. Particles of 2-5 microns settle in the terminalbronchioles due to gravitational precipitation, while those smaller than2 microns are removed by alveolar macrophages and taken away by thelymphatic system of the lungs.

The entire respiratory tract consists of epithelial cells, which differin type and function along the tracheobronchial tree. Ciliated columnarcells characterise the airways from the trachea to the terminalbronchioles. Protruding from their apical surface are the cilia, whichhave the task of moving with a cleaning effect on mucus and any inhaledparticles.

Muciferous goblet cells have the function of secreting mucus, useful formaintaining the correct moisture of the epithelium and trappingparticulate matter. They are present in the broadest sections of theairways, under the small bronchi, but have not been found inbronchioles.

All respiratory system components can be exposed to a series of diseaseswith varying etiologies, often sustained by different pathogenicmicroorganisms which, on becoming preponderant in the microenvironmentand over the flora normally present, cause the disease and consequentlylead to a reduced functionality.

Upper Respiratory Tract Pathologies

Rhinitis

Rhinitis is an inflammatory process affecting the mucosa of the nasalcavities and is distinguished between acute and chronic forms. Acuterhinitis is generally sustained by viruses, including Rhinovirus,Coronavirus, influenza and parainfluenza virus, RSV, Coxsackie virus,ECHO virus and adenovirus. Contagion occurs as a result of directcontact with an ill subject, who, at the peak of contagiousness(generally the first days), will have 500-1000 virions per ml ofsecretion, which he or she emitted through coughs and sneezes. It ispossible for there to be bacterial superinfections, which lead tocomplications such as otitis and sinusitis. The common cold caused byRhinovirus gives rise to acute symptoms in the first 3-4 days, whilstcoughing and other symptoms persist for 7-10 days. There is an excess ofmucus secretions that are fluid and transparent and become purulent andfoul smelling in the event of bacterial superinfection.

The chronic form is generally secondary to sinusitis, nasal septumdeviations and hypertrophic adenoids. Allergic rhinitis is of the acutetype and is due to a subject's exposure to substances that provoke anIgE-mediated reaction, characterised by an excessive production offluids, intranasal itching, sneezing and obstruction. IgE binds tomastocytes, which release large amounts of histamine, responsible forall pathological manifestations.

Recent studies have shown that allergic rhinitis and asthma areconcurrent and to be considered as two manifestations of the entirerespiratory tract, that is, rhinitis does not regard solely the upperpart of the respiratory tract and asthma does not regard solely thelower part of the respiratory tract. In fact, it appears that between20% and 50% of patients with allergic rhinitis also have asthma and from30% to 90% of patients with asthma have concomitant rhinitis. Therefore,allergic rhinitis could be a predisposing factor for the development ofallergic asthma and, more specifically, the sensitisation toaeroallergens (pollen or animal hair) would seem to be an important riskfactor in the association of asthma and rhinitis.

Sinusitis

Sinusitis is an inflammation of the mucosa lining the paranasal sinuses,bone cavities that are situated in the facial skeleton and are incommunication with the nasal fossae, and may thus become infected due tothe same causes responsible for rhinitis. Sinusitis can be distinguishedinto: acute viral or acute bacterial (up to 4 weeks), chronic (over 12weeks) and acute recurrent (at least 4 episodes a year with resolution).

When sinusitis involves the nasal cavity one speaks of rhinosinusitis. Ahealthy sinus is generally sterile, characterised by an appropriatedrainage of mucus and a free passage of air. Ciliary abnormalities orimmobility determine an inhibition of drainage resulting in sinusitis.Factors predisposing to this pathology are an immunocompromised state,nasal septum deviation, nasal polyps, tumours, traumas and fractures,cocaine abuse and the presence of foreign bodies.

An acute viral form of sinusitis can be susceptible to bacterialsuperinfection. The bacteria commonly responsible for these infectionsare Streptococcus pneumoniae, nontypeable Haemophilus influenzae andMoraxella catarrhalis. Pseudomonas aeruginosa is more frequently presentin sinusitis caused by HIV infections and cystic fibrosis. Some generaof fungi such as Candida, Aspergillus, Blastomyces, Coccidioides,Rizophus, Histoplasthma and Cryptococcus can cause sinusitis inimmunocompromised patients.

The signs and symptoms of acute rhinosinusitis consist in: mucopurulentdischarges from the nose, nasal obstruction, congestion, facial pain,pressure on the sinuses involved, hyposmia, anosmia, fever, sensation ofpressure or a “plug” in the ears and toothache. In the first 3-5 days, aviral form cannot be distinguished from a bacterial one, so the use ofantibiotics is not advisable.

If the pathology persists for over 10 days, it will very probably besustained by bacteria and antibiotic treatment is indicated. Chronicforms have a slower onset, longer duration and greater frequency. Thesymptoms are similar to those of the acute form with, in addition, badbreath, laryngitis, bronchitis and a worsening of asthma.

Sinusitis often resolves on its own and treatment is prevalentlysymptomatic. In particular, decongestant treatment serves to reduceoedema, improve the drainage of excess mucus and maintain the patency ofthe sinus ostia. A good result can be obtained in the treatment of theacute bacterial, acute recurrent and chronic forms, as well as inprevention, by local application of a hypertonic saline solution.

The choice of antibiotics must take into account the production of betalactamase and presence of drug-resistant pneumococci.

Pharyngitis (Pharyngotonsillitis)

It is an inflammatory process of the pharynx, hypo pharynx, uvula andtonsils, which is generally transmitted by direct contact withrespiratory secretions. It is more frequent in paediatric age (5-15years) and although it is often self-limiting, the swelling of the partsinvolved can cause a reduced patency of the airways or in any casepreclude the ingestion of adequate amounts of liquids, with consequentdehydration.

The infection can be sustained by viruses (such as Epstein-Barr) andbacteria; in particular, group A beta-haemolytic Streptococcus pyogenesis the most frequent in paediatric forms, but Micoplasthma pneumoniaeand Clamidia pneumoniae as well are found in adults and children. Theforms transmitted through sexual contact and sustained by Neisseriagonorrhoeae and Corynebacterium diphtheriae (form reduced by use of avaccine) should also be considered.

Epiglottitis

It is an inflammation of the epiglottis, caused by a viral or bacterialinfection, which determines a swelling of the organ with a possibleobstruction of the airways.

Epiglottitis is mainly caused by H. influenzae type b, but also bystreptococci, staphylococci or a thermal trauma. It manifests itselfwith ear pain (in adults) and dysphonia, whilst fever is absent in up to50% of cases and can develop at a late stage. The treatment isantibiotic when bacteria are the cause of the disease, whereasintubation may be required in the case of a severe obstruction of theairways.

Laryngitis

It is an inflammation of the larynx that manifests itself with aphoniaand hoarseness, mainly caused by viruses, but also by bacteria(including streptococci and C. diphtheriae) in up to 10% of cases.Non-infectious causes can be tumours, thermal or caustic traumas or GERD(gastroesophageal reflux disease). Laryngitis manifests symptoms lasting3-4 days and no use is made of antibiotics unless bacteria are present.

Lower Respiratory Tract Diseases.

Bronchiolitis

Bronchiolitis, a frequent disease in paediatric age, is characterised byan extensive inflammation of the airways accompanied by an intenseproduction of mucus and necrosis of epithelial cells. It is primarilycaused by a viral infection, particularly by RSV (respiratory syncytialvirus), but also adenovirus, influenza and parainfluenza viruses, humanmetapneumovirus and rhinovirus, whereas the most frequently involvedbacteria are of the genus Clamidia.

In paediatric age the principal clinical manifestations are tachypnea,breathlessness or crackles on auscultation, which generally follow aninfection of the upper respiratory tract.

Treatment can entail hospitalisation if the saturation of oxygen iscomprised between 92% and 94%, together with other clinicalmanifestations such as poor nutrition, dehydration and a history ofdyspnea.

Cystic Fibrosis

This disease is caused by a mutation of the gene that codes for theprotein CFTR, an anion channel expressed in epithelial cells throughoutthe body. Although it functions above all as a chloride ion channel, itis also capable of regulating the function of other membrane proteins,such as the epithelial sodium channel (ENaC), whose activity isinhibited. Among its many functions, CFTR also regulates theintracellular secretion of bicarbonate, which is reduced and determinesa lowering of the epithelial pH with a consequent reduction in theprotection against microbes and an increase in the viscoelasticity ofmucus. The dysfunction of the CFTR channel in the lungs determines anexcessive absorption of sodium and a reduced active secretion ofchlorine, with a consequent reduction in the liquid layer on the surfaceof the mucosa. This leads to an anomalous mucus-ciliary clearance, witha retention of viscous mucus, which favours infections and inflammationand thus lung damage.

Various studies support the hypothesis that the lung damage is alsocaused by the vulnerability of the dehydrated mucosa. Based on this, ithas been hypothesised that hypertonic saline solutions might be a newoption for increasing the hydration of the mucosa and improvingmucus-ciliary clearance.

Bronchiectasis

It is a pathology characterised by an irreversible dilation of a portionof the bronchial tree in the lungs. Bronchial dilation can be the resultof a structural defect of the wall, exposure to an abnormal pressure, ordamage to the cartilage or elastic tissue as a result of aninflammation. Bronchiectasis affects the bronchi and bronchioles, wherea vicious circle of infection and inflammation can arise, also with therelease of mediators. Common symptoms are coughing up mucus and chestpain.

The mucus contains an increased amount of elastase, TNF a, IL-8 andprostanoids. Bronchiectasis can manifest itself as a local obstructiveprocess or a diffuse one involving part of both lobes, also accompaniedby sinusitis or asthma. There are various causes; for example, above allin paediatric age, infections, including mycotic ones, which leavepermanent damage, or else primary ciliary dyskinesias, in which there isa marked retention of the secretions followed by infections. Cysticfibrosis, as well as conditions of immunodeficiency, can be predisposingfactors. It has further been observed that respiratory tract infectionsand bronchiectasis are present in patients with ulcerous colitis.Treatment entails the use of antimicrobials to combat the infectionssustained both by bacteria and fungi. Furthermore, it is particularlyuseful to do lavages of the airways to increase the removal ofsecretions, making use of saline solutions and, as a general rule,keeping the patient well hydrated.

Other respiratory tract pathologies include asthma, chronic obstructivepulmonary disease (COPD) and other obstructive bronchial pathologies.

The pharmacological treatments available for the respiratory tractdisorders listed above generally have scant effectiveness, are largelydependent on the individual response of the affected subjects and mayhave side effects, also major ones, such as skin rash and itching,headache, dizziness, sleep disorders (antibiotics), muscle cramps,tachycardia, trembling, anxiety and bronchial hyperreactivity(β₂-adrenergic agonists).

Other treatments, such as the administration of a hypertonic salinesolution, besides having scant effectiveness, must be repeated a numberof times and for long periods.

There is still a felt need to have a treatment making it possible toprevent or cure respiratory tract disorders without the disadvantages ofthe currently available therapies.

One aim of the present invention is to provide a treatment that makes itpossible to prevent or cure respiratory tract disorders and which iseffective, well tolerated and fundamentally devoid of side effects.

As a solution to said need, the present invention provides a compositionfor use in a treatment method according to the appended claims.

The present invention relates to a composition comprising or,alternatively, consisting of an effective amount of a mixture whichcomprises at least, or consists of:

-   -   a) an extract of Pelargonium sidoides;    -   b) an extract of Adhatoda vasica; and    -   c) N-acetyl cysteine        for use in a method for the preventive or therapeutic treatment        of at least one respiratory tract disorder in a subject, wherein        said treatment method comprises the administration of said        composition to the subject.

The subject matter of the present invention also relates to apharmaceutical composition, dietary supplement or composition for amedical device comprising or, alternatively, consisting of an effectiveamount of a mixture which comprises at least, or consists of:

-   -   a) an extract of Pelargonium sidoides;    -   b) an extract of Adhatoda vasica; and    -   c) N-acetyl cysteine        and at least one inert ingredient or excipient adapted for        pharmaceutical, dietary or nutraceutical use.

The subject matter of the present description also relates to a methodfor the preventive or therapeutic treatment of at least one respiratorytract disorder in a subject, wherein said treatment method comprises theadministration of the composition of the invention to said subject.

Finally, the subject matter of the present description also relates tothe non-therapeutic use of the composition of the invention for thenon-therapeutic, preventive or ameliorative treatment of at least onerespiratory tract disorder in a subject, wherein said use comprises theadministration of the composition of the invention to said subject.

Preferred embodiments of the present invention will emerge clearly fromthe detailed description that follows and are specified in the appendedclaims.

Within the scope of the present invention, the term “airways” indicatesthe upper or lower airways indistinctly, i.e. the composition of theinvention can be active on an upper or lower respiratory tract disorderor on an upper and lower respiratory tract disorder.

Following extensive trials, the inventors have developed a compositioncomprising two natural extracts a) and b) and N-acetyl cysteine c),which has demonstrated high activity in the treatment and/or preventionof respiratory tract disorders. Without being limited by the theory,said high activity can be due to the synergistic action betweencomponents a), b) and c) as indicated above.

Within the scope of the present invention, “treatment method”, or methodfor the treatment of a pathology or disorder, means therapy aimed atrestoring the health conditions of a subject, maintaining the existingconditions and/or preventing the worsening of said health conditions.

Within the scope of the present invention, “prevention” of a pathologyor disorder means therapy aimed at avoiding the onset of such apathology or disorder in a subject, also, but not only, as acomplication or effect of a pre-existing pathological condition ordisorder.

Unless specified otherwise, within the scope of the present inventionthe percentages and amounts of a component in a mixture are intended torefer to the weight of that component relative to the total weight ofthe mixture.

Unless specified otherwise, within the scope of the present invention,in relation to numerical ranges of values for a certain characteristic,the indication “from X to Y” includes the extremes, that is, X and Y, inaddition to all of the possible intermediate numerical values.

In the context of the present invention, the term “composition(s)” isintended to include a pharmaceutical composition, a composition for adietary supplement, a composition for a food product or a compositionfor a medical device.

In one aspect, the present invention provides a composition comprisingor, alternatively, consisting of an effective amount of a mixture whichcomprises at least, or consists of:

-   -   a) an extract of Pelargonium sidoides;    -   b) an extract of Adhatoda vasica; and    -   c) N-acetyl cysteine        for use in a method for the preventive or therapeutic treatment        of at least one respiratory tract disorder in a subject, wherein        said treatment method comprises the administration of said        composition to the subject.

Mucus hypersecretion is a condition characterising various respiratorytract pathologies such as asthma, cystic fibrosis and other obstructivebronchial pathologies. In healthy subjects, the production of mucus isnot excessive and the latter is easily removed by the ciliary cellslining the wall of the respiratory tract. In the presence of somepathologies, mucus hypersecretion may occur or its removal by ciliarycells may be reduced as a result of infections, inflammation orirritation, so that it becomes necessary to use treatments making itpossible to reduce these problems and thereby improve the respiratorycapacity. There exist numerous classes of drugs capable of alleviatingthe symptoms of mucus hypersecretion, such as expectorants, mucolytics,mucoregulators and mucokinetics.

N-acetyl-L-cysteine (NAC or simply N-acetyl cysteine) is the acetylatedform of the amino acid L-cysteine and is presently also used to limitthe toxicity of paracetamol in the event of overdose and as a mucolyticagent.

The mechanism of action consists in reducing the disulphide bridges ofthe proteins present in mucus: this makes it possible to reduce itsviscosity and facilitate its elimination. A further mechanism of actionhas been proposed, based on the anti-inflammatory and antioxidantactivity of this molecule, which could enable a greater reduction of thesymptoms of chronic obstructive pulmonary disease (COPD) with the use ofNAC compared to other pharmacological treatments.

This was demonstrated by the HIACE study, during which it was observedthat in patients affected by COPD there was an improvement in the forcedexpiratory flow, which rose from 25% to 75%, and a reduction inexacerbations (from 1.71 times a year to 0.96). Another series ofstudies likewise suggest the efficacy of using NAC to treat COPD: inthis case it emerged that patients under treatment for six months withthis molecule showed a significant increase in FEV1 (forced expiratoryvolume at the first second) and maximum expiratory flow, whilst anotherstudy showed an increase in FEV1 from 25% to 30% after a brief therapyof 4 weeks. The exacerbations of the pathology were reduced by 0.07exacerbations/month and the days of malaise were reduced by 0.56days/month, which enabled hospitalisations for COPD to be reduced by30%. As previously mentioned, N-acetyl cysteine shows to be effectiveagainst COPD thanks not only to the mucolytic effect, but thanks also tothe anti-inflammatory one. NAC is in fact capable of influencing variousfactors involved in the inflammatory process, thereby reducing thechemotactic capacity of the mucus of patients after 10 months oftreatment and modulating the inflammatory response after 10 weeks ofadministration.

Furthermore, a meta-analysis demonstrated the benefits of prolonged useof N-acetyl cysteine for the treatment and prevention of chronicbronchitis, which has demonstrated to be capable of preventing acuteexacerbations of this pathology. For these reasons, N-acetyl-L-cysteinehas application in the treatment of various pathologies affecting theupper respiratory tract, such as pulmonary emphysema, bronchitis,amyloidosis and COPD. N-acetyl cysteine has demonstrated to be effectivealso in the treatment of cystic fibrosis. With regard to the treatmentof upper and lower respiratory tract infections affecting children whodo not present with chronic bronchopulmonary disorders, the use ofN-acetyl cysteine and carbocysteine has brought about only slightimprovements (reduction of coughing after 7 days), which have littleclinical relevance.

N-acetyl cysteine is also effective in cases of idiopathic pulmonaryfibrosis and numerous mechanisms of action in this pathology have beenproposed.

It has in fact been demonstrated that NAC is capable of inhibiting theaccumulation of collagen in cases of pulmonary fibrosis induced bybleomycin, increasing the amount of glutathione in the bronchoalveolarfluid of patients, and inhibiting various profibrotic mechanisms, suchas increases in the levels of hydroxyproline, collagen, variouscytokines, inflammatory cells, mucus secreting cells and mucin 5subtypes A and C. Furthermore, it has demonstrated effectiveness ininhibiting the epithelial-mesenchymal transition in rat alveolar cellsand reducing the expression of fibronectin, VEGF and α-SMA in humanpulmonary fibroblasts and the concentration of cytokines produced byalveolar macrophages.

At present there are no clinical studies capable of demonstrating thegreater efficacy of N-acetyl cysteine on its own in the treatment ofpulmonary fibrosis, but it emerged from the “IFIGENIA” study thattreatment with NAC, prednisone and azathioprine revealed to be moreeffective than the combination of prednisone+azathioprine (M. Demedts etal., “High-Dose Acetylcysteine in Idiopathic Pulmonary Fibrosis,” N.Engl. J. Med., vol. 353, no. 21, pp. 2229-2242, Nov. 2005).

Numerous studies demonstrate that the combined administration of NAC andhypertonic saline solution could lead to an improvement in respiratoryactivity in numerous pathologies, thanks to the mucolytic action of NACand the expectorant effect of hypertonic saline solutions (DE 41 03 360A1). It was judged that the best route of administration was aerosolinhalation, since in this manner N-acetyl cysteine is in able tointeract directly with the mucoproteins lining the upper respiratorytract. Accordingly, there is a possibility of minimising such sideeffects as nausea, vomiting, drowsiness, headache, rash and fever, whichhave been found in various cases following oral administration of NAC.

Pelargonium sidoides

Pelargonium sidoides is one of the most important species of the genusPelargonium long used in traditional medicine in South Africa.

The popular use of this type of plant was focused on respiratoryinfections and gastrointestinal problems; in particular, the interest inthis plant species has increasingly grown because of its potential useas an antitubercular and as a remedy for earache, colds, tonsillitis,bronchitis, sinusitis and rhinopharyngitis (H. Kolodziej, O. Kayser, O.A. Radtke, A. F. Kiderlen, and E. Koch, “Pharmacological profile ofextracts of Pelargonium sidoides and their constituents” Phytomedicine,vol. 10 Suppl 4, no. February, pp. 18-24, 2003).

From a phytochemical viewpoint, numerous studies have been aimed atidentifying the main metabolites in plant extracts and the presence ofan ample number of metabolites belonging to the classes of coumarins,flavonoids, proanthocyanidins, phenolic acids and phenylpropanoids hasbeen detected. In particular, “umcalin” and other trimethoxy-coumarinsare considered markers of the species Pelargonium sidoides, fordistinguishing it, for example, from the species Pelargonium reniforme,in which these compounds should be absent.

The scientifically recognised effects of P. sidoides are antibacterial,antiviral and immunomodulatory effects attributed, respectively, topolyphenols (gallic acid) and a combination of phenolic compounds andcompounds with a coumarinic structure.

With respect to antibacterial and antifungal activity, a 1997 studyassessed the effect of the individual components (scopoletin, “umcalin”,5,6,7-trimethoxy-coumarin, (+)-catechin, gallic acid and esters thereof)against Gram-positive bacteria (Staphylococcus aureus, Streptococcuspneumoniae, Streptococcus 1451) and Gram-negative bacteria (Escherichiacoli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa,Haemophilus influenzae). All of the components except catechin showedantibacterial activity with an MIC comprised between 200 μg/mL and 1000μg/mL.

The antibacterial activity has also been indirectly evaluated byassessing the ability of an extract of Pelargonium sidoides to inhibitbacterial adhesion (streptococcus) to human epithelial cells. Other invitro studies have shown the plant extract to be capable of increasingphagocytosis, the oxidative response and cell death.

Other studies have confirmed the significant immunomodulatory power ofextracts of Pelargonium, which are capable of stimulating not onlymacrophage activity, but also the release of a series of cytokines thatare fundamental in the immune response, e.g. TNF-α, iNOS, IL-1, IL-10,IL-12, IL-18 and interferon-α, γ. This immunomodulatory action is ofparticular importance, also considering that the majority of infectionsaffecting the upper respiratory tract are due to viruses.

Another documented activity of the plant extract is the ability tostimulate the mucociliary system: an ability of the plant extract (1,30, 100 μg/mL) to increase mucociliary clearance in cultures of humannasal epithelial cells was observed in two studies.

It has emerged from an ample number of clinical trials that the extractof Pelargonium sidoides has good effectiveness and at the same time agood safety of use (side effects are mainly mild and transitory).

The extract of Pelargonium sidoides a) used in the composition of thepresent invention is advantageously an extract of leaves, fruits, seeds,cortex, branches or roots or, alternatively, an extract obtained fromtwo or more of said parts of the plant. Said extract of Pelargoniumsidoides a) used in the composition of the present invention ispreferably a dry hydroalcoholic extract obtained according to standardprocedures known to the person skilled in the art and/or reported in theliterature.

Adhatoda vasica

Adhatoda vasica, also known as Justicia adhatoda L., is a medicinalplant of the family Acanthaceae, native to Asia.

The plant grows spontaneously and abundantly throughout Nepal, India andin the Pothohar region of Pakistan, particularly in the Pharwala area.

Flowering takes place between November and April in flatlands, July andOctober in hilly areas.

Phytochemical studies on this plant have revealed the presence ofalkaloids, phytosterols, polyphenols and glycosides as the principalchemical compounds. The main constituents are quinazoline alkaloids,with vasicine being the most representative compound. In addition tovasicine, the leaves and roots of this plant contain other alkaloids,such as I-vasicinone, deoxyvasicine, maiontone, vasicinolone andvasicinol.

The leaves are rich in vitamin C and carotenoids. The chemical compoundspresent in the leaves and roots of the plant include essential oils,fats, resins, sugars, amino acids and vitamins.

Adhatoda has been used in traditional medicine to treat respiratorydisorders. Vasicine and vasicinone are known as therapeutic agents forthe treatment of respiratory tract disorders. The extracts of the leavesand roots of Adhatoda are used for the treatment of bronchitis and otherpathologies of the bronchioles and lungs, such as coughing and colds.The bronchodilating activity of vasicine has been demonstrated both invitro and in vivo. Vasicinone, the principal metabolite of vasicine, hasshown bronchodilating activity in vitro, but bronchoconstrictingactivity in vivo. The anti-tussive activity has been demonstrated in invivo studies on guinea pigs and rabbits. Recent studies on vasicine havedemonstrated its bronchodilating activity both in vitro and in vivo.

Another pharmacological property that is very useful for the purpose oftreating respiratory pathologies may be antibacterial activity. In vitrostudies have demonstrated the strong activity of the alkaloids ofAdhatoda against the bacteria Pseudomonas aeruginosa, Streptococcusfaecalis, Staphylococcus aureus and Escherichia coli.

Vasicine and vasicinone have also demonstrated to have anti-allergicactivity. In an in vivo study, an extract containing vasicinol andvasicine at a dose of 5 mg demonstrated to inhibit the allergic responseinduced by ovalbumin by 37%.

The extract of Adhatoda vasica b) used in the composition of the presentinvention is advantageously an extract of leaves, roots or flowers or,alternatively, an extract obtained from roots and/or leaves; it ispreferably an extract of leaves. Said extract of Adhatoda vasica b)preferably used in the composition of the present invention is a dryextract obtained according to standard procedures known to the personskilled in the art and/or reported in the literature.

Extracts a) and b) and N-acetyl cysteine c) have demonstrated asynergistic action, i.e. more than additive, in the prevention andtreatment of lower and/or upper respiratory tract pathologies. Forexample, the composition according to the present invention makes itpossible to obtain the therapeutic effects obtainable with high doses ofN-Acetyl cysteine despite a reduction in the amount of NAC actuallyadministered, thus significantly decreasing the possibility of sideeffects.

The present invention makes it possible to obtain, simultaneously:

-   -   Mucolytic effect;    -   Antimicrobial effect.

N-acetyl cysteine has the ability to reduce the disulphide bridges ofmucin. In this manner, NAC reduces the viscosity of mucus. Adhatodavasica also shows mucolytic activity which, combined with thebronchodilating activity, is capable of contributing further to thewellbeing of the respiratory tract.

Extract of Pelargonium sidoides is endowed with antimicrobial activityagainst many microorganisms, including bacteria and viruses which can bethe cause of pathologies affecting the respiratory tract. Anotherinteresting activity of Pelargonium sidoides is its immunomodulatoryactivity, which should contribute further to preventing infections thatare a cause of respiratory tract pathologies.

The synergistic action takes place between N-Acetylcysteine, extract ofPelargonium sidoides and extract of Adhatoda vasica, particularly, butnot exclusively, when N-acetyl cysteine is present in an amount of 100mg to 1500 mg, preferably 200 mg to 1200 mg; the extract of Pelargoniumsidoides is present in an amount of 1 mg to 500 mg, preferably 1 mg to100 mg, more preferably 10 mg to 60 mg; and the extract of Adhatodavasica is present in an amount of 50 mg to 2000 mg, preferably 75 mg to800 mg, more preferably 100 mg to 600 mg.

The composition according to the present invention is preferably for usein a treatment method of at least one respiratory tract disorder fromamong rhinitis, sinusitis, pharyngitis, epiglottitis, laryngitis,bronchiolitis, cystic fibrosis, chronic obstructive pulmonary diseaseand bronchiectasis.

The composition according to the present invention is preferably for usein the aforesaid treatment method comprising administration via theoral, nasal or inhalation route.

The composition according to the present invention is preferably in theform of liquid composition for oral use and/or a powder that is solubleor dispersible in a liquid.

In the composition for use according to the present invention, saidmixture preferably comprises an amount of extract of Pelargoniumsidoides a) of 1 to 100 mg, more preferably 10 to 60 mg.

In the composition for use according to the present invention, saidmixture preferably comprises an amount of extract of Adhatoda vasica a)of 50 to 100 mg, more preferably 75 to 800 mg, even more preferably 100to 500 mg.

In the composition for use according to the present invention, saidmixture preferably comprises an amount of N-acetyl cysteine ranging from50 to 2000 mg, preferably 200 to 1200 mg.

In the composition for use according to the present invention, saidmixture preferably comprises an extract of Pelargonium sidoides a) andan extract of Adhatoda vasica b) in an a):b) weight ratio of 1:2 to1:50, preferably 1:5 to 1:30 or 1:9 to 1:20.

In the composition for use according to the present invention, saidmixture preferably comprises an amount of N-acetyl cysteine c) in aweight ratio with the total weight of the extract of Pelargoniumsidoides a) and extract of Adhatoda vasica b), c): [a)+b)] ranging from50:1 to 1:10, preferably 30:1 to 1:3 or 10:1. to 6:1.

The composition according to the present invention is preferably for thetherapeutic or preventive treatment of at least one respiratory tractdisorder from among rhinitis, sinusitis, pharyngitis, epiglottitis,laryngitis, bronchiolitis, cystic fibrosis and bronchiectasis.

The composition according to the present invention can be for use inhuman subjects, also, but not only, of paediatric age, or for veterinaryuse, for example, but without limitation, in pets such as dogs or cats,or in other mammals. The composition according to the present inventionis preferably for use in humans.

In one embodiment, the administration of the composition to the subjecttakes place orally, for example in the form of a tablet, pill, alsocoated, capsule, mouth-dissolving powder, solution, suspension, alsoobtained by dissolution or suspension of a powder in a liquid such as anaqueous medium, syrup, food containing extracts a) and b) and N-acetylcysteine c) or in any other form known to the person skilled in the art.

In one embodiment, the administration of the composition to the subjecttakes place by inhalation, for example in the form of an aerosol,nebulised suspension or nasal or oral spray.

It remains understood that the administration of extracts a) and b) andN-acetyl cysteine c) according to the invention can take placesimultaneously, for example in a single formulation, or in rapidsequence, for example by means of two or more formulations taken by thesubject in any order, in a sequence closely spaced over time (e.g.within 1 to 10 minutes) in two or more distinct compositions.

The composition for use according to the present invention may comprise,in addition to extracts a) and b) and N-acetyl cysteine c), at least oneinert ingredient, such as at least one excipient among those commonlyused and known to the person skilled in the art.

“Inert ingredient” means any substance, or combination of substances,auxiliary to the production of a pharmaceutical, dietary ornutraceutical form, which is to be found in the finished product and isnot the active ingredient, although it can modify the stability, releaseor other characteristics thereof.

Non-limiting examples of such ingredients, as known to the personskilled in the art of formulations in the pharmaceutical, nutraceuticalor food sectors, are diluent, absorbent, adsorbent, lubricant, glidant,colouring, surfactant, antioxidant, sweetening, flavouring, binding,disintegrating, plasticising, viscosity enhancing, emulsifying,humectant, wetting, preservative and chelating excipients and the like.

In one embodiment, the composition for use according to the presentinvention comprises, in addition to extracts a) and b) and N-acetylcysteine c), at least one further active ingredient of natural orsynthetic origin. Non-limiting examples of said active ingredients arethiamine, riboflavin, pantothenic acid, niacin, biotin and ascorbicacid.

In a preferred embodiment, the composition for use according to thepresent invention contains, in addition to extracts a) and b) andN-acetyl cysteine c), at least one other active ingredient selected fromamong extracts of Hedera helix L., hederagenin, Glycyrrhiza glabra L.,glycyrrhizic acid, 18β-glycirrhetic acid, Papaver rhoeas L., Grindeliahumilis Nutt., Eucalyptus globulus Labill. and 1,8-cineole.

In one aspect, the present invention provides a pharmaceuticalcomposition, dietary supplement or composition for a medical devicecomprising or, alternatively, consisting of an effective amount of amixture which comprises at least, or consists of:

-   -   a) an extract of Pelargonium sidoides;    -   b) an extract of Adhatoda vasica; and    -   c) N-acetyl cysteine        and at least one inert ingredient or excipient adapted for        pharmaceutical, dietary or nutraceutical use.

In the context of the present invention, the term “medical device” isused with the meaning according to Italian Legislative Decree no. 46 of24 Feb. 1997, and Directive 93/42/EEC of 14 Jun. 1993, i.e. it indicatesa substance or another product, whether used alone or in combination,intended by the manufacturer to be used for human beings for the purposeof diagnosis, prevention, monitoring, treatment or alleviation of adisease, and which does not achieve its principal intended action in oron the human body for which it is intended by pharmacological,immunological or metabolic means, but which may be assisted in itsfunction by such means.

The pharmaceutical composition, dietary supplement or composition for amedical device of the present invention can be solid, liquid orsemisolid, for example a suspension or gel, and it can be in any formknown to the person skilled in the art of food, pharmaceutical ornutraceutical formulations; by way of non-limiting example, in the formof a capsule, tablet, or powder that is at least partially dissolvablein the mouth or water soluble, granules, pellets or microparticlesoptionally contained in a sachet or in a capsule or mini-tablet, aliquid or semisolid preparation, gel, suspension, solution, two-phaseliquid system and equivalent forms.

Non-limiting examples of compositions according to the present inventionare represented by:

Example 1

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 300 mg Pelargonium sidoides  30 mg d.e.: dry extract Pharmaceuticalform: Sachets.

Example 2

Active ingredient Daily dose N-Acetylcysteine 1,200 mg Adhatoda vasica,d.e. 600 mg Pelargonium sidoides 60 mg Pharmaceutical form: Sachets.

Example 3

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 300 mg Pelargonium sidoides  30 mg Pharmaceutical form: Bottle oforal liquid.

Example 4

Active ingredient Daily dose N-Acetylcysteine 200 mg Adhatoda vasica,d.e. 100 mg Pelargonium sidoides  20 mg Pharmaceutical form: Bottle oforal liquid.

Example 5

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 100 mg Pelargonium sidoides  20 mg Pharmaceutical form: Sachets.

Example 6

Active ingredient Daily dose Adhatoda vasica, d.e. 300 mgN-Acetylcysteine 100 mg Pelargonium sidoides  10 mg Pharmaceutical form:Bottle of oral liquid.

The following experimental part provides examples of practicalembodiments of the invention, without limiting the scope thereof.

EXPERIMENTAL PART

1) Material

The pharmaceutical forms illustrated below are prepared according tostandard techniques known to the person skilled in the art for thepreparation of solid and liquid compositions for pharmaceutical,nutraceutical and/or dietary use in humans.

Example 1

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 300 mg Pelargonium sidoides  30 mg Pharmaceutical form: Sachets.

Example 2

Active ingredient Daily dose N-Acetylcysteine 1,200 mg Adhatoda vasica,d.e. 600 mg Pelargonium sidoides 60 mg Pharmaceutical form: Sachets.

Example 3

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 300 mg Pelargonium sidoides  30 mg Pharmaceutical form: Bottle oforal liquid.

Example 4

Active ingredient Daily dose N-Acetylcysteine 200 mg Adhatoda vasica,d.e. 100 mg Pelargonium sidoides  20 mg Pharmaceutical form: Bottle oforal liquid.

Example 5

Active ingredient Daily dose N-Acetylcysteine 600 mg Adhatoda vasica,d.e. 100 mg Pelargonium sidoides  20 mg Pharmaceutical form: Sachets.

Example 6

Active ingredient Daily dose Adhatoda vasica, d.e. 300 mgN-Acetylcysteine 100 mg Pelargonium sidoides  10 mg Pharmaceutical form:Bottle of oral liquid.2) Methods

The effectiveness of the composition of the present invention in amethod for the treatment of at least one respiratory tract disorderand/or the synergistic action of components a), b) and c) of thecomposition itself was assessed using in vitro and in vivo methods knownto the person skilled in the art, as described below.

The anti-inflammatory activity of the individual components compared tothe combination thereof (composition of the present invention) andcompared to the control was assessed in vitro. Specifically, mousemonocyte/macrophage J774 cell lines were selected and grown in DMEM(Dulbecco's Modification of Eagle Medium) with the addition ofglutamine, Hepes, penicillin, foetal bovine serum and sodium pyruvate.The cells were plated and kept in an incubator at a controlledtemperature and atmosphere. Cell viability was assessed by means of theMTT assay (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide)and the growth thereof was subsequently stimulated. At this point,specific methods were used to measure the concentration of nitrites,levels of TNF-α and IL-1β as parameters for assessing anti-inflammatoryactivity.

The antimicrobial activity of the composition of the present inventionwas assessed in vitro. Suitable assays include broth dilution (with thecalculation of the MIC, or minimum inhibitory concentration, and MBC, orminimum bactericidal concentration) and diffusion in agar (where astandardised concentration of the sample is applied in a broth cultureof bacteria and the diffusion of the sample within the medium iscalculated). The antimicrobial activity was assessed in the mainbacterial strains belonging to the Gram-positive and/or Gram-negativecategories and/or other microbial species.

The antioxidant activity of the composition of the present invention, ofparticular interest for alleviating respiratory tract disorders, wasassessed in vitro. Suitable in vitro assays include, for example: DPPHassay (nitrogen radical 2,2-diphenyl-1-picrylhydrazyl), radicalscavenging activity on nitric oxide or on the peroxynitrile radical,TEAC assay (total radical-trapping antioxidant parameter), FRAP (ferricreducing-antioxidant power), HORAC (hydroxyl radical averting capacity),ORAC (oxygen radical absorbance capacity) and the like.

The expectorant activity of the composition of the present invention wasassessed in vivo in CD1® mice. Specifically, the animals were treatedwith different formulations (e.g. individual active components, activecomponents in association, vehicle, control) administered orally.Several minutes after treatment, the animals received an intraperitonealinjection of phenol red; the mice were subsequently anaesthetised, theupper front part of the neck was shaved and the trachea was exposed. Themice then underwent a tracheobronchial lavage with saline solution andthe lavage fluid was subsequently recovered and centrifuged. As aparameter for evaluating the expectorant activity, the post-lavageconcentration of red phenol was measured by spectrophotometry.

The anti-tussive effect of the composition of the present invention wastested in an in vivo model of guinea pigs with coughing provoked byinhalation of capsaicin. The anaesthetised animals were exposed to anebulised aqueous solution of capsaicin and during exposure they wereobserved constantly in order to assess the number of coughing episodes.The majority of coughing episodes occurred within 10 minutes, which wasthe time then established as the duration of exposure. This modelproposes pre-treating the guinea pigs with the active components of thepresent invention (a), b) and c)) orally administered, individually orin a mixture (composition according to the invention), 30 minutes beforeinhalation with capsaicin, to demonstrate how the number of coughingepisodes is considerably reduced by the synergistic action of thecomponents compared to the same ones tested individually.

The invention claimed is:
 1. A composition comprising asynergistically-effective amount of a mixture of: a) an extract ofPelargonium sidoides; b) an extract of Adhatoda vasica; and c) N-acetylcysteine.
 2. The composition according to the claim 1, wherein saidcomposition is formulated for inhalation.
 3. The composition accordingto the claim 1, wherein the composition is formulated as anaerosolizable powder or liquid.
 4. The composition according to claim 1,wherein said mixture comprises an amount of extract of Pelargoniumsidoides a) ranging from 1 mg to 100 mg; an amount of extract ofAdhatoda vasica b) ranging from 50 mg to 1000 mg; and/or an amount ofN-acetyl cysteine ranging from 50 mg to 2000 mg.
 5. The compositionaccording to claim 1, wherein said mixture comprises an extract ofPelargonium sidoides a) and an extract of Adhatoda vasica b) in a weightratio in the range of 1:2 to 1:50.
 6. The composition according to claim1, wherein said mixture comprises an amount of N-acetyl cysteine in aweight ratio with the total weight of the extract of Pelargoniumsidoides a) and extract of Adhatoda vasica b) ranging from 50:1 to 1:10.7. A pharmaceutical composition, dietary supplement or composition for amedical device comprising a synergistically-effective amount of amixture of: a) an extract of Pelargonium sidoides; b) an extract ofAdhatoda vasica; and c) N-acetyl cysteine and at least one inertingredient or excipient adapted for pharmaceutical, dietary ornutraceutical use.
 8. The composition of claim 1, wherein thecomposition is formulated for oral administration.
 9. The composition ofclaim 8, wherein the composition is formulated as a capsule, tablet,powder or liquid.